APPLICATION GLATFELTER COMMERCIAL AMBULANCE - TEXAS

Transcription

1 183 Leader Heights Road P.O. Box 2726, York, PA Fax: GlatfelterCommercialAmbulance.com Return completed application to: APPLICATION GLATFELTER COMMERCIAL AMBULANCE - TEXAS GENERAL INFORMATION Date of Application: Current Carrier and Agency: Date Proposal Needed By: Expiration Date: Type of Organization: Individual Partnership Corporation Joint Venture Other (Describe: ) Legal Name of Organization: (List all legal entities to be included as a Named Insured.) Federal Employer Identification Number (FEIN): Organization s Mailing Address: Street or PO Box City County State Zip Code Organization s fax number: ( ) Organization s website: Contact person s name: Title: Day phone: ( ) Evening phone: ( ) address: Is this individual (check all that apply): the contact for inspection purposes? If not, contact: Phone: the contact for education and training purposes? If not, contact: Phone: the head of the organization? Is the company a private for-profit ambulance service? Yes No If no, please describe: Is the company hospital owned? Yes No In business for how long? How long has the current ownership been in place? Describe any name changes or acquisitions made in the last three years, or anticipated in the coming year: May 2016 TX Edition 1

2 REAL & PERSONAL PROPERTY Yes No Current Premium: Coverage type desired: Scheduled Building Scheduled Contents Blanket Contents Deductible desired: $500 (Standard) $1,000 $2,500 $5,000 Premises # Item # Building Occupied As: Owner or Tenant? Total Area of Building (including all floors) Street Address City, State, Zip Code Premises # Item # Building Amount of Insurance Contents ($5,000 minimum) Protection Class Construction Code * Sprinkler System Y / N Mortgagee Name and Address * Construction codes: 1 frame 4 masonry noncombustible 7 heavy timber joisted masonry 2 joisted masonry 5 modified fire resistive 8 superior noncombustible 3 noncombustible 6 fire resistive 9 superior masonry noncombustible Premises # Item # Year Built Age of electrical system if more than 35 years old If more than one entity is insured, to which one is this property assigned? Occupied 24 hours per day? Y / N Are there any structures at this premises that you don t want to insure? If so, describe them below and make sure their values are not included in the amount of insurance requested above. May 2016 TX Edition 2

3 GENERAL LIABILITY / PROFESSIONAL HEALTH CARE LIABILITY Yes No Current General Liability Carrier: Occurrence Claims-Made Retroactive Date: Professional Healthcare Liability Occurrence Claims-Made Retroactive Date: Current Premium: $ Limits Desired: $500,000 occ. / $1,000,000 agg. Occurrence Claims-made Retroactive Date: $1,000,000 occ. / $2,000,000 agg. Occurrence Claims-made Retroactive Date: $1,000,000 occ. / $3,000,000 agg. Occurrence Claims-made Retroactive Date: Annual Revenue: This Year % from Medicaid /Medicare Last Year % from Insurance Companies % from Private Pay % from Contract What is your primary service area? County(s) Does your organization service any major metropolitan areas? Yes No Do you operate in other states? Yes No If so, what state(s): Do you own any aircraft or watercraft in excess of 100 hp? Yes No Do you perform any aircraft or watercraft transportation? Yes No Are any medical clinical services offered? Yes No Do you operate a call/ dispatch center/ PSAP or secondary PSAP? Yes No Is there a written procedure for identification and handling of true emergency requests for service? Yes No Are event standby services offered? Yes No Identify any medical facilities for which you have an exclusive transport service contract: May 2016 TX Edition 3

4 TOTAL number of calls per year: Medical Calls: Emergency Medical Ambulance Calls (was dispatched as an emergency): Non-Emergency Medical Ambulance Calls (was not dispatched as an emergency): Non-Medical / Paratransit Calls: Wheelchair Calls (wheelchair transportation): Other Transportation Services Calls (buses, fly cars or unmodified vans): Services Other Than Transport Calls (social services; community paramedicine): CALL HISTORY / HISTORICAL COUNT 1 st Prior Year 2 nd Prior Year 3 rd Prior Year 4 th Prior Year 5 th Prior Year Medical Calls Emergency Medical Ambulance Calls Non-Emergency Medical Ambulance Calls Non-Medical / Paratransit Calls Wheelchair Calls Other Transportation Services Calls Services Other Than Transport Calls Total Calls Describe the highest level of EMS service provided: Advanced Life Support Basic Life Support Intermediate Life Support No EMS Indicate the highest level of medical training of the insured s personnel accounting for all employees that have medical duties (including your medical director) in the table below. Full-Time Employee Part-Time Employee Basic CPR # # First Responder # # EMT (Basic) # # EMT (Intermediate/Advanced) # # Paramedic # # Nurse (LPN or RN) # # Physician, Surgeon, Osteopath # # Other, please describe: # # May 2016 TX Edition 4

5 Indicate the procedures used in the employee selection process: Written Application Physical Examination Written Test Road Test Other (describe: Pre-employment drug testing Criminal Background check Reference checks MVR check Do you utilize a Medical Director? Yes No If yes, provide the following: Name: Phone Number: Employee or Contracted Service Full-Time or Part-Time If Medical Director is a Physician, Surgeon or Osteopath do they carry their own professional liability insurance? Yes If yes, please indicate insurance carrier and policy limits: (A certificate of insurance evidencing the above information will be required to bind.) No Do you employ or contract physicians for critical care transport or other medical services? Yes No If yes, are they required to carry their own professional liability insurance? Yes No If yes, please indicate insurance carrier and policy limits: (A certificate of insurance evidencing the above information will be required to bind.) Is a standard call report completed on each call, and each time an ambulance is requested? Yes No If no, please explain: Who reviews the standard call reports for completeness, legibility and quality? When are these reviews completed? Daily Weekly Monthly What percentage of reports are reviewed? Do you have formal medical protocols and procedures in place for patient care? Yes No If yes, please indicate if protocols are in accordance with State EMS standards. Yes No Do you have a formalized specialized training program for patient handling / lifting? Yes No Annual in-house training? Yes No Who performs the maintenance of the lifting equipment used? Do you maintain and monitor records on an on-going basis to confirm that all employees and new hires meet appropriate state certification requirements? Yes No Do you provide any specialized medical transport service, such as neo-natal transport or specialized cardiac transport? Yes No Have you entered into any written agreement with others to perform ambulance services for you? Yes No If Yes, please forward a copy of all such contracts. Do you borrow or lease employees from others? Yes No If Yes, please forward a copy of all such contracts including hold harmless conditions. May 2016 TX Edition 5

6 Do you lend or lease employees to others? Yes No If Yes, please forward a copy of all such contracts including hold harmless conditions. Has any claim been made or suit filed against the company and/or its employees in the past five years alleging negligence in the rendering, or failure to render, medical or professional health care services? Yes No Does the insured have any knowledge of any matter which would cause a reasonable person to believe that a claim or suit against the company is likely to arise alleging negligence in the rendering, or failure to render, medical or professional health care services? Yes No With respect to medical professional liability insurance for the insured, has any insurance policy been canceled or non-renewed, or an application for insurance been declined, or refused in the past five years? Yes No With respect to medical professional liability insurance, has the company received notice of any claims by a state regulatory agency in the past five years? Yes No AUTO Yes No Current Business Auto Carrier: Current Premium: $ Limit Desired (Combined Single Limit): $500,000 $1,000,000 "No Fault" or Personal Injury Protection: $2,500 Uninsured Motorist / Underinsured Motorist: $85,000 (Combined Single Limit) $100,000 Physical Damage Deductibles: Comprehensive $1,000 $3,000 Collision $1,000 $3,000 $5,000 $5,000 Radius of your operations: 0-50 miles % miles % over 150 miles % What is the largest city entered within your radius of operation? How often is a maintenance report completed on each vehicle and the equipment? May 2016 TX Edition 6

7 Who maintains your vehicles? If you have paratransit / wheelchair vans, who maintains the lifts? How often? Are there written procedures in place addressing: Use of patient s wheelchair for transport Yes No Securement of wheelchairs Yes No Proper use of lifts Yes No Are maintenance records kept on file? Yes No Are vehicles locked when unattended? Yes No Do you allow third parties (other than patient or personnel) to ride in the ambulance? Yes No Do you maintain an accident review committee? Yes No Do you maintain accident files? Yes No If yes, for how long? What is your minimum driver age? Are drivers required to have at least 3 years driving experience? Yes No Number of currently employed drivers: Full Time Part Time What was the percentage of your driver turnover in the past 12 months? % Do you review driver motor vehicle reports? Yes No How often? Annually Every 2-3 years More than 3 years Do you have written driver qualifications that include criteria for acceptable MVR s? Yes No If yes, PLEASE PROVIDE COPY Do you have a formal written driver training program? Yes No Are your vehicles equipped with driver monitoring devices? Yes No (ie. Drive Cam, Road Safe) Do all drivers of vehicles with 16 or more passengers, including the driver, carry a CDL? Yes No Do you own or lease any 15 passenger vans? Yes No If yes, please answer the following questions: Are all vans equipped with ESC (Electronic Stability Control) Yes No Are all drivers at least 23 years of age and have adequate prior experience operating a 15 passenger van? Yes No Is care taken to prevent overloading of vans with passengers and luggage? Yes No Are passengers required to wear seatbelts or the appropriate child restraints? Yes No Are all van drivers thoroughly trained on the placement of passengers and cargo? Yes No Is there a requirement that no loads are placed on the roof of the vans? Yes No Are records retained on all activities regarding the vans, including but not limited to all of the above? Yes No May 2016 TX Edition 7

8 VEH # 1 YEAR VEHICLE MAKE DESCRIPTION (MODEL / TYPE) VEHICLE CLASS (below) SERIAL NUMBER (VIN) SEATING CAPACITY (ACV) COST NEW AGREED VALUE COMP. COVERAGE Y/N COLLISION COVERAGE Y / N TERR VEHICLE CLASSES: ALS (ADVANCED LIFE SUPPORT AMBULANCE) BLS (BASIC LIFE SUPPORT AMBULANCE) LIV (AMBULETTE OR WHEELCHAIR VAN) PPT (PRIVATE PASSENGER VEHICLE) OTH (SERVICE VEHICLES AND ALL OTHER) May 2016 TX Edition 8

9 Do any of your vehicles require an Additional Insured or Loss Payee to be listed on the policy? Yes No Name & Address: Vehicle # A.I L.P. Name & Address: Vehicle # A.I L.P. Name & Address: Vehicle # A.I L.P. FLEET HISTORY / VEHICLE COUNT 1 st Prior Year 2 nd Prior Year 3 rd Prior Year 4 th Prior Year 5 th Prior Year Ambulances (ALS and BLS) Ambullete and Wheelchair Private Passenger All Other Total PORTABLE EQUIPMENT Yes No Indicate the type of coverage needed: Blanket Scheduled Blanket and Scheduled Choose a deductible: $1,000 $2,500 $5,000 For blanket coverage, you must complete the Vehicle Class column on the vehicle schedule. Account for all vehicles owned by the organization or furnished to the organization for regular use. Use the codes defined on page 8. For scheduled coverage, please provide the following for each item insured. Attach a separate sheet if necessary. Item Number Description Serial Number Unit Value Quantity May 2016 TX Edition 9

10 CRIME Yes No Do checks require at least two signatures? Yes, in excess of $ No Do purchases require the signed approval of two or more people? Yes, in excess of $ No Are bank accounts reconciled by someone not authorized to deposit or withdraw? Yes No Are criminal background checks done on all employees as part of the hiring process? Yes No If no, are criminal background checks completed on officers and/or management personnel? Yes No Are financial records audited by outside parties? Yes No If yes, how often? Please indicate the entity to be covered by the bond. Employee Dishonesty Limit: $ Name or Position Schedule Bond Name or Position Covered Entity (if more than one) Limit Answer only if you ve requested both Employee Dishonesty and a Name or Position Schedule bond. Is the Name or Position Schedule bond intended to be: Primary Specific excess over the Employee Dishonesty Note: Forgery or Alteration, Computer Fraud and Identity Fraud Expense are coverage extensions that are only available if Employee Dishonesty was requested. Forgery or Alteration Limit: $25,000 $50,000 $100,000 $250,000 $500,000 Computer Fraud: $25,000 $50,000 Identity Fraud Expense: $25,000 $50,000 May 2016 TX Edition 10

11 MANAGEMENT LIABILITY Yes No EMPLOYMENT RELATED PRACTICES AND EMPLOYEE BENEFITS LIABILITY Choose limits: $300,000 each offense or wrongful act / $1,000,000 aggregate $500,000 each offense or wrongful act / $1,000,000 aggregate $1,000,000 each offense or wrongful act / $2,000,000 aggregate $1,000,000 each offense or wrongful act / $3,000,000 aggregate Claims made basis Does the applicant have knowledge of any incidents which would cause a reasonable person to believe that a claim or suit might result? Yes No If Yes, please give complete details, including date: Occurrence basis Please indicate whether the applicant: is currently insured on an occurrence basis for ML coverage, or does not currently carry ML coverage, or will purchase an extended reporting period from their current claims made carrier when they move their coverage to Glatfelter Commercial Ambulance Does the organization have a personnel (human resources) administrator? Yes No Does the organization have written policies and procedures covering the following areas? Hiring or applying for membership Yes No Discipline Yes No Dismissal Yes No Promotions Yes No Discrimination Yes No New employee / volunteer orientation Yes No Sexual Harassment Yes No Performance evaluation Yes No N/A IMPORTANT NOTE: When coverage is bound, a completed and signed Supplement C will be required if coverage is on a claims made basis. Consider getting the appropriate signature now. CYBER LIABILITY AND PRIVACY CRISIS MANAGEMENT EXPENSE COVERAGE C AND D OF MANAGEMENT LIABILITY Cyber Liability protects you when claims are made against you for monetary damages arising out of an electronic information security event. The limit for Each Electronic Information Security Event will be the same as the Management Liability each offense or wrongful act limit, subject to the Management Liability aggregate. Privacy Crisis Management Expense reimburses for expenses you incur as a result of a privacy crisis management event first occurring during the policy period. This first party coverage is intended to provide professional expertise in the identification and mitigation of a privacy breach while satisfying Federal and State statutory requirements. $50,000 each privacy event / $50,000 aggregate automatically included $100,000 each privacy event / $100,000 aggregate $250,000 each privacy event / $250,000 aggregate Yes No Do you have firewall management software installed on your computer network? Yes No Do you have antivirus management software installed on your computer network? Yes No Do you have a written security and privacy policy? May 2016 TX Edition 11

12 Cyber Liability and Privacy Crisis Management Expense Comments: EXCESS LIABILITY Yes No Limits Desired: $ occurrence / $ aggregate Note: Underlying limits of $1,000,000 are required. Coverage desired over: General Liability Management Liability Automobile Liability (Check all that apply) WRAP-UP INFORMATION Any special information the underwriter should know? IMPORTANT: Be sure to include current premium information, loss runs for the past five years, and most current GAAP prepared financial statement. Has the applicant s insurance program been cancelled or non-renewed by another carrier? Yes No If Yes, please provide details: Name of producing agency: Agency s address: Agency s phone: ( ) Agency s fax: ( ) Agency s address: If you are not licensed as a broker, are you a property / casualty agent? Yes No Name and address of producer or CSR (for contact purposes): May 2016 TX Edition 12

13 PLEASE READ CAREFULLY --- GENERAL FRAUD WARNING NOTICE Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime and may subject the person to criminal and civil penalties. STATE-SPECIFIC FRAUD WARNING NOTICES Alabama Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arkansas Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information on an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado Fraud Warning It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Delaware Fraud Warning Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime and may subject the person to criminal and civil penalties. Florida Fraud Warning Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kansas Fraud Warning Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer or insurance agent or broker, any written statement as part of, or in support of, an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially false information concerning any material fact thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. Kentucky Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Louisiana Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Maine Fraud Warning It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland Fraud Warning Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Hampshire Statement of Residency To procure automobile insurance, I hereby attest that I am, and each named insured is, a resident of the State of New Hampshire. I understand that if I falsely claim for myself or any named insured to be a resident of the State of New Hampshire, I am subject to prosecution, imprisonment of up to one year, a fine of $2,000 and the denial of coverage for any loss, not occurring in New Hampshire, under the automobile insurance policy for which I am applying. I also understand that this statement will be relied upon in connection with future renewals of the automobile insurance policy for which I am applying, and that it is my responsibility to inform my insurance company before my next renewal after I or any named insured ceases to be a New Hampshire resident and that I will be subject to the penalties listed above if I fail to do so. New Jersey Fraud Warning Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New Mexico Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. May 2016 TX Edition 13

14 New York Fraud Warning Auto: All applications for automobile insurance shall contain the following statement: Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. Fire Insurance: All applications for fire insurance shall contain the following statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. The proposed insured affirms that the foregoing information is true and agrees that these applications shall constitute a part of any policy issued whether attached or not and that any willful concealment or misrepresentation of a material fact or circumstances shall be grounds to rescinding the insurance policy. Other Types of Insurance: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. Ohio Fraud Warning Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma Fraud Warning WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon Fraud Warning Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law. Pennsylvania Fraud Warning All Types of Insurance: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Motor Vehicle Insurance: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000. Rhode Island Warning All Types of Insurance: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Property Insurance: Failure to disclose the existence of an arson conviction within the past ten (10) years of this application can result in a criminal penalty. Tennessee Fraud Warning It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Vermont Fraud Warning Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Virginia Fraud Warning It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Washington Fraud Warning It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. West Virginia Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Your signature below acknowledges that you have read the General Fraud Warning Notice and the State Specific Fraud Warning Notice that applies to your state of domicile. The undersigned is an authorized representative of the applicant and certifies the information provided to obtain this coverage is accurate to the best of their knowledge; this includes any applications, locations schedules, valuation statements, loss history information and engineering reports. Applicant s signature: Title: Date: Agent s signature: Date: May 2016 TX Edition 14